MEDICARE: WELLSTAR MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician		GA

General Provider Information

NPI Number	:	1518263656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSTAR MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	121 MARBLE MILL RD NW
Second Line	:	SUITE 101
City	:	MARIETTA
State	:	GA
Zip	:	30060-7959
Country	:	US
Telephone Number	:	770-422-8315
Fax Number	:	770-590-9170

Provider Business Practice Location Address
First Line	:	121 MARBLE MILL RD NW
Second Line	:	SUITE 101
City	:	MARIETTA
State	:	GA
Zip	:	30060-7959
Country	:	US
Telephone Number	:	770-422-8315
Fax Number	:	770-590-9170

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR OF FINANCE
Name	:	NICOLE ASHE
Credential	:
Telephone Number	:	470-644-0095

Provider Enumeration Date	:	02/08/2011
Last Update Date	:	11/18/2013

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